Utilization review is required to pre-certify inpatient hospitalization days and certain medical procedures. The program consists of:
• pre-certification for the following non-emergency services before medical and/or surgical services are provided:
• Inpatient Hospitalization
• Scheduled Outpatient Surgery requiring implants (i.e. pacemaker/defibrillators, cataracts, cochlear implants)
• Chemotherapy
• Radiation
NOTE: The following Outpatient Services DO NOT require pre-certification:
• Ultrasounds
• Blood Tests
• EEG’s
• Echos
• Simple X-Rays
• EMG’s
• EKG’s
• Flexible Sigmoidoscopies
• retrospective review of emergency inpatient admissions;
• concurrent review, based on the admitting diagnosis, when an extension of the pre-certified inpatient days is requested by the attending Physician; and
• certification of services and planning for discharge from a Medical Care Facility or cessation of medical treatment.
The attending Physician does not have to obtain pre-certification from the Plan for prescribing a maternity length of stay that is 48 hours or less for a vaginal delivery or 96 hours or less for a cesarean delivery.
Utilization Review is required for non-emergency and emergency Hospital admissions. The utilization review administrator does not approve Employee or Dependent eligibility for Plan benefits. All claims
must be submitted to the Plan for processing to determine the amount of benefits, if any, to be paid under the terms of the Plan.
This program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician or other health care provider. If a particular course of treatment or medical service is not certified, it means that the Plan will not consider that course of treatment as appropriate for the maximum reimbursement under the Plan.
The Covered Person is free to choose any Physician or surgeon, and the Physician-patient relationship shall be maintained. The Covered Person, together with the treating Physician, is ultimately responsible for determining the appropriate course of medical treatment, regardless of whether the Plan will pay for all or a portion of the cost of such care.
In order to maximize Plan reimbursements, please read the following provisions carefully.
HERE’S HOW THE PROGRAM WORKS:
Pre-Certification − Before a Covered Person enters a Medical Care Facility on a non-emergency basis or receives other listed medical services, the utilization review administrators will, in conjunction with the attending Physician, certify the number of inpatient Hospital days that are approved. A non-emergency stay in a Medical Care Facility is one that can be scheduled in advance. Pre-certification is not a guarantee that services will be paid.
The utilization review program is set in motion by a telephone call from the Covered Person. Contact the utilization review administrator at the telephone number on your ID card at least 48 hours before services are scheduled to be rendered with the following information:
! the name of the patient and relationship to the covered Employee,
! the name, identification Number and address of the covered Employee,
! the name of the Employer,
! the name and telephone number of the attending Physician,
! the name of the Medical Care Facility, proposed date of admission, and proposed length of stay,
! the diagnosis and/or type of surgery, and
! the proposed rendering of listed medical services.
If there is an emergency admission to the Medical Care Facility, the patient, patient’s family member, Medical Care Facility or attending Physician must contact the utilization review administrator within 48 hours of the first business day after the emergency inpatient admission.
The utilization review administrator will authorize the number of days of Medical Care Facility confinement. Failure to follow this procedure may reduce reimbursement received from the Plan. If the Covered Person does not receive authorization as explained in this section, the benefit payment will be reduced as shown in the Schedule of Benefits.
Concurrent Review/Discharge Planning − Concurrent review of a course of treatment and discharge planning from a Medical Care Facility are parts of the utilization review program. The utilization review administrator will monitor the Covered Person’s Medical Care Facility stay or use of other medical services and coordinate with the attending Physician, Medical Care Facilities and Covered Person either the scheduled release or an extension of the Medical Care Facility stay.
If the attending Physician feels that it is Medically Necessary for a Covered Person to receive additional services or to stay in the Medical Care Facility for a greater length of time than has been pre-certified, the attending Physician must request the additional services or days no later than 24 hours before the end of the original pre-certified number of days or services.
1. Call the utilization review administrator before all non-emergency inpatient Hospital stays and within 48 hours of the first business day after an emergency inpatient admission.
2. The utilization review administrator reviews and approves hospitalization days based on the Physician’s diagnosis and treatment plan. It does not approve Employee or Dependent eligibility, and it does not approve charges as Covered Charges under the Plan. All claims must be submitted to the Plan for processing under Plan terms.
3. If the Plan’s Pre-Existing Condition exclusion period applies to the Covered Person, pre-certification by the utilization review administrator does not mean the Plan will be liable for charges relating to the Pre-Existing Condition during the Pre-Existing Condition exclusion period.
4. If you do not follow the utilization review procedures, payment for Covered Charges under the Plan will be reduced.
CASE MANAGEMENT
When a catastrophic condition such as a spinal cord Injury, cancer, AIDS or a premature birth occurs, a person may require long-term, perhaps lifetime, care. After the person’s condition is diagnosed, he or she might need extensive services or might be able to be moved into another type of care setting − even to his or her home.
Case Management is a program whereby a case manager monitors these patients and explores, discusses and recommends coordinated and/or alternate types of appropriate Medically Necessary care. The case manager consults with the patient, the family and the attending Physician. This plan of care may include some or all of the following:
• personal support to the patient;
• contacting the family to offer assistance and support;
• monitoring Hospital or Skilled Nursing Facility;
• determining alternative care options; and
• assisting in obtaining necessary equipment and services.
Case Management occurs when this alternate benefit will be beneficial to both the patient and the Plan.
The case manager will coordinate and implement the Case Management program by providing guidance and information on available resources and suggesting the most appropriate treatment plan.
The Plan Administrator, attending Physician, patient and patient’s family must all agree to the alternate treatment plan.
Once agreement has been reached, the Plan Administrator will direct the Plan to reimburse for Medically Necessary expenses as stated in the treatment plan, even if these expenses normally would not be paid by the Plan.
Note: Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate.
Each treatment plan is individually tailored to a specific patient and should not be seen as appropriate or recommended for any other patient, even one with the same diagnosis.
CONCIERGE PROGRAM
This Plan includes a Medical Concierge Program. The Concierge Program is designed to assist the Covered Person in locating the highest quality provider (based upon national statistics) for services
rendered. Providers approved by the Concierge are authorized to be paid as Network Providers. The Concierge will negotiate with the selected Provider for the best reimbursement rate for both the Covered Person and the Plan costs, which in turn will help premium costs.
The Covered Person will need to contact the Concierge prior to scheduling the following services; the Concierge phone number is listed on the Covered Person’s ID card:
• Inpatient Hospital Services, including: Surgery, medical, maternity and cardiac
• Outpatient Surgeries: Defined as follows: Any operative procedure done at a free-standing or hospital setting by a physician to correct, repair, diagnose and/or cure an identified medical condition, disease or injury. (Includes colonoscopies)
• Chemotherapy
• Radiation Treatment
• PET Scan, MRI or CT Scan
• Physical Therapy, Occupational Therapy and/or Speech Therapy
• Home Health Care
• Transplant workups
• Durable Medical Equipment over $5,000.00
• Kidney Dialysis
NOTE: A Provider calling for Pre-certification does not satisfy the Covered Person’s obligation to call the Concierge and will result in a penalty of $250.00. Failure to follow Pre-certification and/or Medical Concierge requirements will each result in a penalty of $250.00.
The following terms have special meanings and when used in this Plan will be capitalized.
Active Employee is an Employee who is on the regular payroll of the Employer and who is scheduled to perform the duties of his or her job with the Employer on a full-time or part-time basis. Where the Plan requires a Waiting Period, an Employee shall be deemed to be an Active Employee if the Employee is absent from work due to a health factor on any day of the Waiting Period, including the first day of Plan coverage on completion of the Waiting Period. Where the Plan does not require a Waiting Period, in order for an Employee's coverage to become effective, an Employee must begin work. If the Employee is unable to begin work as scheduled, then Plan coverage will become effective on such later date, if any, when the Employee reports to work with the Employer for the work hours originally scheduled.
Adverse Benefit Determination means any of the following:
1. A denial in benefits;
2. A reduction in benefits;
3. A rescission of coverage;
4. A termination of benefits; or
5. A failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Claimant’s eligibility to participate in the Plan.
Allowable Charge means the Usual and Customary charge for any Medically Necessary, Reasonable, and eligible items of expense, at least a portion of which is covered under a Plan. When some Other Plan pays first in accordance with the Application to Benefit Determinations Section, this Plan’s Allowable Charge shall in no event exceed the Other Plan’s Allowable Charge. When some Other Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered, in the amount that would be payable in accordance with the terms of the Plan, shall be deemed to be the benefit. Benefits payable under any Other Plan include the benefits that would have been payable had claim been duly made therefore.
In the case of HMO (Health Maintenance Organization) plans, this Plan will not consider any charges in excess of what an HMO Provider has agreed to accept as payment in full. Further, when an HMO is primary and the Covered Person does not use an HMO Provider, this Plan will not consider as Allowable Expenses any charge that would have been covered by the HMO had the Covered Person used the services of an HMO Provider.
Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery, has a staff of Physicians, has continuous Physician and nursing care by registered nurses (R.N.s) and does not provide for overnight stays.
Baseline shall mean the initial test results to which the results in future years will be compared in order to detect abnormalities.
Birthing Center means any freestanding health facility, place, professional office or institution which is not a Hospital or in a Hospital, where birth occurs in a home-like atmosphere. This facility must be licensed and operated in accordance with the laws pertaining to birthing centers in the jurisdiction where the facility is located.
The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse-midwife; and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post-delivery confinement.
Calendar Year means January 1st through December 31st of the same year.
Child and/or Children means, in addition to the Employee’s own blood descendant of the first degree other Child for whom the Employee has obtained legal guardianship.
CHIP refers to the Children’s Health Insurance Program or any provision or section thereof, which is herein specifically referred to, as such act, provision or section may be amended from time to time.
Chiropractic Services relates to all care rendered in a chiropractor’s office, and includes but is not limited to skeletal adjustments, manipulation or other treatment in connection with the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human body.
Such treatment is done by a Physician to remove nerve interference resulting from, or related to, distortion, misalignment, or subluxation of, or in, the vertebral column.
Claims Administrator means the third party administrator which provides customer service and claims payment services only and does not assume any financial risk or obligation with respect to investigation for fraud and abuse or claims under review for Medical Necessity and Reasonableness, or fees under review for Usual and Customariness, or any other matter that may prevent the charge(s) from being Covered Expenses in accordance with the terms of this document.
Filing a Clean Claim. A Provider submits a Clean Claim by providing the required data elements on the standard claims forms, along with any attachments and additional elements or revisions to data elements, attachments and additional elements, of which the Provider has knowledge. The Plan Administrator may require attachments or other information in addition to these standard forms (as noted elsewhere in this document and at other times prior to claim submittal) to ensure charges constitute Covered Expenses as defined by and in accordance with the terms of this document. The paper claim form or electronic file record must include all required data elements and must be complete, legible, and accurate. A claim will not be considered to be a Clean Claim if the Covered Person has failed to submit required forms or additional information to the Plan as well.
Clinical Trial means trials to evaluate the effectiveness and safety of medications or medical devices by monitoring their effects on large groups of people. This Plan cannot:
1. deny an individual participation in an approved clinical trial conducted in relation to prevention, detection or treatment of cancer or another life-threatening disease or condition;
2. deny, limit or impose additional conditions on the Plan’s coverage for items and services furnished in connection with participation in the clinical trial if the items or services would ordinarily be covered under the plan if the individual were not enrolled in the clinical trial;
or
3. discriminate against an individual on the basis of his or her participation in the clinical trial.
Clinical Trial - Approved is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in connection with the prevention, detection, or treatment of cancer or other life-threatening disease or condition that is likely to result in death unless the course of the condition is interrupted. In addition, the clinical trial must be a study or investigation conducted under a new drug application reviewed by the Food and Drug Administration (or be exempt from having such an investigational new drug application) or the trial must be approved or funded by specified government agencies.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
Complications of Pregnancy are determined as follows:
These conditions are included before the Pregnancy ends: acute nephritis; ectopic Pregnancy;
miscarriage; nephrosis, cardiac decompensation; missed abortion; hyperemesis gravidarum; and eclampsia of Pregnancy.
Other Pregnancy related conditions will be covered that are as medically severe as those listed.
These conditions are not included: false labor; occasional spotting; rest during Pregnancy even if prescribed by a Physician; morning Sickness; or like conditions that are not medically termed as Complications of Pregnancy.
Cosmetic means any surgery, service, drug or supply designed to improve the appearance of an individual by alteration of a physical characteristic which is within the broad range of normal but which may be considered unpleasing or unsightly, except when necessitated by an Injury.
Covered Expense(s) means a Usual and Customary fee for a Reasonable, Medically Necessary service, treatment or supply, meant to improve a condition or Covered Person’s health, which is eligible for coverage in this Plan. Covered Expenses will be determined based upon all other Plan provisions.
All treatment is subject to benefit payment maximums shown in the Summary of Benefits and as determined elsewhere in this document.
Covered Person means an Employee, Retired Employee or Dependent who is covered under this Plan.
Creditable Coverage includes most health coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO membership, an individual insurance policy, Medicaid, Medicare, and a State Children’s Health Insurance Program (SCHIPS). Creditable coverage also includes coverage under a public health plan of a state, city, county or other government subdivision, or of the U.S. or of any foreign country. Creditable Coverage does not include coverage consisting solely of dental or vision benefits.
Custodial Care means care (including room and board needed to provide that care) that is given principally for personal hygiene or for assistance in daily activities and can, according to generally accepted medical standards, be performed by persons who have no medical training. Examples of Custodial Care are help in walking and getting out of bed; assistance in bathing, dressing, feeding or supervision over medication that could normally be self-administered.
Dentist means a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license.
Dependent means one or more of the following person(s):
1. An Employee’s lawfully married spouse possessing a marriage license who is not divorced from the Employee;
2. An Employee’s Child who is less than 26 years of age; or
3. An Employee’s Child, regardless of age, who was continuously covered prior to attaining the limiting age as stated in the numbers above, who is mentally or physically incapable of sustaining his or her own living. Such Child must have been mentally or physically incapable of earning his or her own living prior to attaining the limiting age as stated in the numbers above. Written proof of such incapacity and dependency satisfactory to the Plan must be furnished and approved by the Plan within 60 days after the date the Child attains the limiting age as stated in the numbers above. The Plan may require, at reasonable intervals, subsequent proof satisfactory to the Plan during the next two years after such date. After such two-year period, the Plan may require such proof, but not more often than once each year.